Membership Application | Texas Orthodontic Study Club

Please fill out this form and remit payment for your Annual Membership dues.

Membership is subject to the validation of credentials and a vote by the membership.

* Please note it takes approximately 2 weeks from the day you apply to process your application.

Status

Quantity

Price: $300.00

Hidden

Quantity

Name

First Last

Office Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Website

Mobile Phone

Office Phone

Dental School and Year Graduated?

Orthodontic School and Year Graduated?

Earned

DDS

DMD

Certified in Orthodontics

MS in Orthodontics

ABO Certified? Include Date.

Dental License in the State of? Include Dates.

AAO Member? If so are you Active or Associate?

Constituent Society?

Local, State, and National Orthodontic Associations/Organizations/Societies/Study Groups in which you are a member in good standing?

Extended Orthodontic Course(s) you have taken?

Please tell us about yourself. Where you live and practice, interests, family, what you do for fun, etc.

I hereby apply for membership in the Texas Orthodontic Study Club. I have read and understand the bylaws and agree to comply with them.

Please type your name here as your signature.

Date

TOSC Member who referred you?

Coupon

Total

Credit Card

Name

This field is for validation purposes and should be left unchanged.